Chapter 19- Disorders of Cardiac Function
The nurse would anticipate that which of the following clients would be considered a good candidate for coronary artery bypass grafting (CABG)?
A 56-year-old with a history of MI experiencing new-onset chest pain and ST elevation Explanation: Coronary artery bypass grafting (CABG) may be the treatment of choice for people with significant coronary artery disease (CAD) who do not respond to medical treatment and who are not suitable candidates for percutaneous coronary intervention. CABG does not address valve disorders, pericardial effusion, or cardiomyopathies.
What is the most common identifiable cause of secondary cardiomyopathy?
Alcohol abuse Explanation: Alcohol abuse is a cause of secondary cardiomyopathy, while the other options result in primary cardiomyopathy.
The nurse is preparing to auscultate for a mitral valve stenosis murmur Where is the best location to place the stethoscope
At the apex of the heart Explanation: The murmur of mitral valve stenosis is heard during diastole when blood is flowing through the constricted valve; it is characteristically a low-pitched, rumbling murmur best heard at the apex of the heart. The other locations would not be effective.
The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states that blood is shunted from the:
Left side of the heart to the right side of the heart Explanation: Defects that result in a left-to-right shunt are categorized as acyanotic disorders since they do not compromise oxygenation of blood in the pulmonary circulation
The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states that blood is shunted from the:
Left side of the heart to the right side of the heart Explanation: Defects that result in a left-to-right shunt are categorized as acyanotic disorders since they do not compromise oxygenation of blood in the pulmonary circulation.
The nurse is teaching a patient with a diagnosis of hypertrophic cardiomyopathy and aortic valve stenosis. Which of the following statements by the patient shows that the patient understands this condition?
"I should report episodes of dizziness or fainting." Explanation: Hypertrophic cardiomyopathy is defined as unexplained thickening of the left ventricle leading to reduced cardiac output and obstructive outflow. It can cause sudden cardiac death in athletes after exertion. Treatment includes beta blockers to reduce outflow obstruction. The calcium channel blocker verapamil may be used but is avoided in patients with severe outflow obstruction. Patients should pace activity and avoid alcohol. Episodes of dizziness or fainting could indicate reduced cardiac output and should be evaluated.
A 78-year-old man has been experiencing nocturnal chest pain over the last several months, and his family physician has diagnosed him with variant angina. Which of the following teaching points should the physician include in his explanation of the man's new diagnosis?
"I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising." Explanation: Aspirin, exercise, and weight loss are all identified treatments for angina. Angina does not normally necessitate blood work, heparin administration, or avoidance of activity.
On a routine physical exam visit, the physician mentions that they hear a new murmur. The patient gets worried and asks, "What does this mean?" The physician responds:
"One of your heart valves is not opening properly. We need to do an echocardiogram to see which valve is having problems." Explanation: Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. Blood flow through a normal valve can increase by 5-7 times the resting volume. Valvular disease is not caused by stress. The murmur can be caused by infection but also stenosis or regurgitation of a valve leaflet. The valve problem is very severe if it is causing signs of decrease cardiac output.
A client who has been diagnosed with mitral valve prolapse asks the nurse if there are any dietary modifications that should be incorporated into her lifestyle. The best response would be:
"Refraining from caffeine, alcohol, and cigarettes may be sufficient to control symptoms." Explanation: The treatment of mitral valve prolapse focuses on the relief of symptoms and the prevention of complications. In many cases, the cessation of stimulants such as caffeine, alcohol, and cigarettes may be sufficient to control symptoms. Tea and energy drinks may contain caffeine or stimulants and should be avoided. All nicotine products should be avoided.
Which of the following teaching points would be most appropriate for a group of older adults who are concerned about their cardiac health?
"The plaque that builds up in your heart vessels obstructs the normal flow of blood and can even break loose and lodge itself in a vessel." Explanation: Stable plaque is associated with obstruction of blood flow, while unstable plaque may dislodge and result in thrombus formation. Plaque disruption is noted to correlate with sympathetic events and is not seemingly random; infections and respiratory problems are not noted to be associated, however.
A client who came to the emergency room and was diagnosed with ST-segment elevation myocardial infarction (STEMI) experienced "sudden death." The emergency room nurse explains sudden death from a STEMI as death that occurs within what time frame of symptom onset?
1 hour Explanation: Sudden death from STEMI is death that occurs within one hour of symptom onset.
During an acute MI, there is ischemic damage to the heart muscle. The location and extent of the ischemic damage is the major predictor of complications, ranging from cardiac insufficiency to death, following an MI. What is the "window of opportunity" in restoring blood flow to the affected area so as to diminish the ischemic damage to the heart and maintain the viability of the cells?
20 to 40 minutes Explanation: If blood flow can be restored within the 20-to-40-minute time frame, loss of cell viability does not occur or is minimal.
The nurse working in the emergency room triages a client who comes in with complaints of chest pain, shortness of breath, sweating and elevated anxiety. The physician suspects a myodardial infarction. The client is given a nitrate, which does nothing for his pain. Which of the following medications should the nurse suspect the doctor will order next for the pain?
Morphine Explanation: Although a number of analgesic agents have been used to treat pain of myocardial infarction, morphine is the drug of choice and is usually indicated if chest pain is unrelieved with oxygen and nitrates.
A nurse is assessing a child who has a congenital heart defect for cyanosis. Select the most important area for the nurse to assess.
Mucous membranes Explanation: Cyanosis, a bluish color of the skin, most notable in the nail beds and mucous membranes, develops when sufficient deoxygenated blood from the right side of the heart mixes with oxygenated blood in the left side of the heart.
The nurse is developing a plan of care for a client diagnosed with stable angina. Select the most important goal for this client.
Myocardial infarction prevention Explanation: Symptom reduction for quality of life and prevention of MI are treatment goals for stable angina. The other options would not be treatment goals for stable angina.
A client who is relatively healthy is seen in the clinic for a regular checkup. While there he tells the nurse that he is worried that he may develop a heart condition. When the nurse asks him why he is worried he tells her that his mother had aortic valve stenosis and is afraid that he might get it. He then asks to be tested for the disease. What should the nurse tell this patient about diagnosing a valvular defect?
Valvular defects usually are detected through cardiac auscultation. Explanation: Although valvular heart disease can result from congenital defects, rheumatic heart disease, trauma and other causes, atrial stenosis is usually first diagnosed with auscultation of a loud systolic murmur or a single split second heart sound. Other tests are not used initially.
Mitral valve prolapse occurs frequently in the population at large. Its treatment is aimed at relieving the symptoms and preventing complications of the disorder. Which drug is used in the treatment of mitral valve prolapse to relieve symptoms and aid in preventing complications?
Β-Adrenergic-blocking drugs Explanation: Persons with palpitations and mild tachyarrhythmias or increased adrenergic symptoms and those with chest discomfort, anxiety, and fatigue often respond to therapy with the Β-adrenergic-blocking drugs. None of the other types of drugs are used in the treatment of mitral valve prolapse to relieve symptoms or prevent complications.
The nursing student, when studying about coronary artery disease, learns that it is commonly divided into different types of disorders which include which of the following? Select all that apply.
• Acute coronary syndrome • Chronic ischemic heart disease Explanation: Coronary heart disease is commonly divided into 2 types of disorders: the acute coronary syndrome and chronic ischemic heart disease.
When a client suffers from a pericardial effusion which of the following are considered to be factors that will influence what effects it will have on cardiac function? Select all that apply.
• Amount of fluid • Rapidity with which it accumulates • The elasticity of the pericardium Explanation: The amount of fluid, the rapidity with which it accumulates, and the elasticity of the pericardium determine the effect the effusion has on cardiac function. The presence of an infection and the nutritional status of the client have no effect.
The nursing student correctly identifies which of the following as major risk factors for coronary artery disease? Select all that apply.
• Cigarette smoking • Elevated LDL • Diabetes • Abdominal obesity Explanation: Major risk factors for coronary artery disease include cigarette smoking, elevated blood pressure and LDL, diabetes, advanced age, abdominal obesity, and physical inactivity, just to name a few. Decreased blood pressure and elevated HCL (good cholesterol) are not contributors.
The nursing student, when studying cardiomyopathies, learns that the primary ones are classified into which of the following groups? Select all that apply.
• Genetic • Mixed • Acquired Explanation: The primary cardiomyopathies are classified as genetic, mixed, or acquired, based on their etiology.
A client has been diagnosed with mitral valve stenosis following his recovery from rheumatic fever. Which of the following teaching points would be most accurate to convey to the client? You selected: "Your heart's mitral valve isn't closing properly so blood is flowing backwards in your heart and eventually into your lungs."
"Your mitral valve isn't opening up enough for blood to flow into the part of your heart that sends blood into circulation." Explanation: Mitral valve stenosis represents the incomplete opening of the mitral valve during diastole with left atrial distention and impaired filling of the left ventricle. It does not exist in the right side of the heart and the problem is associated primarily with improper ventricular filling and with pulmonary backflow only secondarily. Though it is often caused by infection, it is not an infectious process of the valve per se
A client with a known history of intravenous drug abuse has been diagnosed with infective endocarditis. Select the most likely cause of infection.
Staphylococcus aureus Explanation: While all of these bacteria can cause infective endocarditis, Staphylococcus aureus is the major offender in injection drug abusers, whereas prosthetic heart valve infective endocarditis tends to be caused by coagulase-negative staphylococci (e.g., Staphylococcus epidermidis).
Heart failure in an infant usually manifests itself as tachypnea or dyspnea, both at rest and on exertion. When does this most commonly occur with an infant?
During feeding Explanation: Heart failure manifests itself as tachypnea or dyspnea at rest or on exertion. For the infant, this most commonly occurs during feeding. The other answers are incorrect.
Tetralogy of Fallot is a congenital condition of the heart that manifests in four distinct anomalies of the infant heart. It is considered a cyanotic heart defect because of the right-to-left shunting of the blood through the ventricular septal defect. A hallmark of this condition is the "tet spells" that occur in these children. What is a tet spell?
A hypercyanotic attack brought on by periods of stress Explanation: The degree of obstruction may be dynamic and can increase during periods of stress causing hypercyanotic attacks ("tet spells"). None of the other answers occur in association with tetralogy of Fallot or tet spells.
ST-elevated myocardial infarction is accompanied by severe, crushing pain. Morphine is the drug of choice used to treat the pain of STEMI when the pain cannot be relieved with oxygen and nitrates. Why is morphine considered the drug of choice in STEMI?
Action decreases metabolic demands of the heart. Explanation: Although a number of analgesic agents have been used to treat the pain of STEMI, morphine is usually the drug of choice. It usually is indicated if chest pain is unrelieved with oxygen and nitrates. The reduction in anxiety that accompanies the administration of morphine contributes to a decrease in restlessness and autonomic nervous system activity, with a subsequent decrease in the metabolic demands of the heart. Morphine does not cause a feeling of depression to the client.
It is known that over 100 distinct myocardial diseases can demonstrate clinical features associated with dilated cardiomyopathy (DCM). What is the most common identifiable cause of DCM in the United States?
Alcoholic cardiomyopathy Explanation: Alcoholic cardiomyopathy is the single most common identifiable cause of DCM in the United States and Europe. The other answers are incorrect.
Four patients were admitted to the emergency department with severe chest pain. All were given preliminary treatment with aspirin, morphine, oxygen, and nitrates and were monitored by ECG. Which patient most likely experienced myocardial infarction?
An 80-year-old woman whose pain started at 6 a.m. shortly after awakening and was not relieved by nitrates or rest; the ECG showed ST-segment elevation with inverted T waves and abnormal Q waves; levels of cardiac markers subsequently rose Explanation: The chest pain of myocardial infarction does not respond to rest or to nitrates. Ischemic injury to the myocardium alters the ECG patterns, often elevating the ST segment and inverting T waves. Abnormal Q waves indicate necrosis. Cardiac markers are released in response to myocardial injury; rising levels indicate damage to the heart. The other patients have angina of varying severity.
The nursing instructor teaches the students that when a client is suffering from pericarditis he/she will have a friction rub. The student asks the instructor what a friction rub is. What would be her best response?
An audible medical sign that is high-pitched and results from the rubbing and friction between the inflamed pericardial surfaces. Explanation: Pericardial friction rub is described as an audible medical sign that is high-pitched or scratchy, and results from the rubbing and friction between the inflamed pericardial surfaces.
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?
Have the client sit up and lean forward. Explanation: With acute periocarditis, the pain typically is pleuritic (aggravated by inspiration and swallowing) and positional (decreases with sitting and leaning forward; increases with moving to the side) because of changes in venous return and cardiac filling
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?
Have the client sit up and lean forward. Correct Explanation: With acute periocarditis, the pain typically is pleuritic (aggravated by inspiration and swallowing) and positional (decreases with sitting and leaning forward; increases with moving to the side) because of changes in venous return and cardiac filling.
A client is admitted to the intensive care unit suspected of having infective endocarditis. Which of the following tests is the most definitive diagnostic procedure that is done and used to guide treatment for this type of client?
Blood culture Explanation: The blood culture remains the most definitive diagnostic procedure and is essential to guide treatment. An echo, ECG, clinical findings and lab information are also used to help in the diagnosis.
What is the most important factor in myocardial oxygen demand?
Heart rate Explanation: The heart rate is the most important factor in myocardial oxygen demand since as heart rate increases, myocardial oxygen demands increase. The degree of affect the other options have on myocardial oxygen demand is related to how much affect they have on heart rate.
A client who has been admitted to the ICU with a diagnosis of pericardial effusion begins to experience severe tachycardia. Upon assessment the nurse finds that his central venous pressure is increased, he has jugular vein distention, his systolic blood pressure has dropped, and there is a narrow pulse pressure. His heart sounds appear to be very muffled. Which diagnosis should the nurse suspect the physician will make?
Cardiac tamponade Explanation: Pericardial effusion can lead to a condition called cardiac tamponade in which there is compression of the heart. It can be life-threatening and symptoms include tachycardia, elevated central venous pressure, jugular vein distention, fall in systolic blood pressure with narrowed pulse pressure. Pericarditis is inflammation of the pericardium. A myocardial infarction does not have these symptoms nor does a thrombus.
The nursing instructor is teaching her nursing students about cardiac function and different heart diseases. Which of the following disease does she tell the students is caused by calcified scar tissue that develops between the visceral and parietal layers of the serous pericardium?
Constrictive pericarditis Explanation: In constrictive pericarditis, fibrous, calcified scar tissue develops between the visceral and parietal layers of the serous pericardium. Acute pericarditis is due to inflammation of the pericardium. Pleural effusion is caused by accumulation of fluid and can lead to cardiac tamponade.
When an acute MI occurs, many physiologic changes occur very rapidly. What causes the loss of contractile function of the heart within seconds of the onset of an MI?
Conversion from aerobic to anaerobic metabolism Explanation: The principal biochemical consequence of MI is the conversion from aerobic to anaerobic metabolism with inadequate production of energy to sustain normal myocardial function. As a result, a striking loss of contractile function occurs within 60 seconds of onset. None of the other answers occur.
A patient who experienced an ST elevation myocardial infarction (STEMI) received fibrinolytic therapy with streptokinase. Which of the following manifestations alerts the nurse to a developing complication?
Decreased level of consciousness Explanation: Fibrinolytic therapy is most effective in treating STEMI when administered within 30 minutes after the onset of symptoms. It can still be beneficial up to 12 hours after the onset of ischemic pain. Patients who should not receive fibrinolytic therapy are those with a history of intracranial hemorrhage or significant trauma within the preceding 3 months. The primary complication of fibrinolytic treatment is intracranial bleeding that usually occurs within the first 24 hours following treatment. This would be evident with a change in mental status.
A 34-year-old man who is an intravenous drug user has presented to the emergency department with malaise, abdominal pain, and lethargy. The health care team wants to rule out endocarditis as a diagnosis. Staff of the department would most realistically anticipate which of the following sets of diagnostics?
Echocardiogram, blood cultures, temperature Explanation: An echocardiogram would help visualize the heart, while blood cultures would confirm the presence or absence of microorganisms in circulation and temperature would gauge the presence of infection. A chest X-ray, blood pressure measurement and cardiac catheterization would be less likely to indicate infective endocarditis
A patient with mitral valve regurgitation and left heart failure reports shortness of breath and fatigue with activities of daily living. Which of the following instructions by the nurse will be ineffective in reducing these symptoms?
Elevating legs for 20 minutes daily Explanation: Mitral regurgitation can lead to reduced cardiac output and left heart failure. Elevating the legs would promote venous return and increase the fluid volume the heart needs to pump, thus exacerbating the symptoms.
Angina pectoris is a chronic ischemic CAD that is characterized by a symptomatic paroxysmal chest pain or pressure sensation associated with transient myocardial ischemia. What precipitates an attack of angina pectoris?
Emotional stress Explanation: Angina pectoris usually is precipitated by situations that increase the work demands of the heart, such as physical exertion, exposure to cold, and emotional stress. The pain typically is described as a constricting, squeezing, or suffocating sensation. It usually is steady, increasing in intensity only at the onset and end of the attack. Changing positions abruptly does not cause an attack of angina pectoris.
The nursing instructor is teaching about cardiomyopathies in class. Which type does she tell the students is the most common cause occurring in young athletes?
Genetic Explanation: Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young athletes. It actually occurs in one person out of every 500.
The health care provider is discussing major risk factors for coronary artery disease (CAD) with a client. The most important information for the provider to include would be:
History of cigarette smoking and elevated blood pressure Explanation: The major risk factors for CAD include cigarette smoking, elevated blood pressure, elevated LDL cholesterol, low HDL cholesterol, diabetes, advancing age, abdominal obesity, and physical inactivity.
A client has just been told that he has an infection of the inner surface of the heart. He is also told that the bacteria has invaded his heart valves. What term is used for this disease process?
Infective endocarditis Explanation: Infective endocarditis is a serious and potentially life-threatening infection of the inner surface of the heart. Pericarditis involves an inflammatory response of the pericardium. Myocardial infarction is a heart attack while cardiomyopathy is a heart disorder that is confined to the myocardium and can sometimes represent myocardial changes that occur with a variety of systemic disorders.
A client who has suffered a myocardial infarction is being treated in the emergency room. His pain remains severe even though he was given nitrates and oxygen. The physician now orders morphine for the pain. What method should the nurse to administer the morphine?
Intravenous Explanation: Morphine is given intravenously when a patient is in the emergency room suffering a myocardial infarction. It is given intravenously because of the rapid onset of action, and it does not elevate enzyme levels.
Which of the following patients with cardiomyopathy does the nurse identify as having the greatest risk for a complication?
One with an ejection fraction of 25% and atrial fibrillation Explanation: Although each set of symptoms is characteristic of cardiomyopathy, the nurse determines the greatest risk occurs with the patient showing evidence of stasis in the heart that can result from a reduced ejection fraction and atrial fibrillation. This patient is most likely to experience an embolus.
A client with a long history of stable angina suddenly experiences substernal pain that radiates to the left arm, neck, and jaw. He describes the pain as severe and feels as if he is suffocating. He has taken nitroglycerin and not experienced any relief. The client is most likely experiencing:
Onset of STEMI Explanation: The onset of STEMI involves abrupt and significant chest pain. The pain typically is severe, often described as being constricting, suffocating, and crushing. Substernal pain that radiates to the left arm, neck, or jaw is common, although it may be experienced in other areas of the chest and back. Unlike that of angina, the pain associated with MI is more prolonged and not relieved by rest or nitroglycerin.
A nurse is assessing a client diagnosed with severe mitral valve stenosis. The nurse anticipates the assessment will include:
Orthopnea Explanation: The symptoms of mitral valve stenosis are those of pulmonary congestion, including nocturnal paroxysmal dyspnea and orthopnea. Atrial tachycardia and atrial fibrillation develop in 30% to 40% of clients with mitral valve stenosis. Transient ischemic attacks occur more frequently in persons with mitral valve prolapse.
A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250ML of fluid in the pericardial cavity. Which disease should the nurse suspect this client to be suffering?
Pericardial effusion Explanation: Pericardial effusion refers to the accumulation of fluid in the pericardial vacuity, usually as a result of an inflammatory or infectious process. A sudden accumulation of even 200ml of fluid may raise intracardiac pressure to levels that will cause symptoms similar to right-sided heart failure. Pericarditis is inflammation of the pericardium while COPD is a respiratory disease.
Exudate in the pericardial cavity is a characteristic of which cardiac condition?
Pericardial effusion Explanation: Pericardial effusion, either acute or chronic, refers to the presence of an exudate in the pericardial cavity. Acute pericarditis is characterized by chest pain, ECG changes, and pericardial friction rub. Cardiac tamponade represents a life-threatening compression of the heart resulting from excess fluid in the pericardial sac. In constrictive pericarditis, scar tissue develops between the visceral and parietal layers of the serous pericardium. In time, the scar tissue contracts and interferes with cardiac filling.
A client comes to the emergency room exhibiting signs and symptoms of right-sided heart failure. Upon X-ray it is determined that he has 250ML of fluid in the pericardial cavity. Which disease should the nurse suspect this client to be suffering?
Pericardial effusion Explanation: Pericardial effusion refers to the accumulation of fluid in the pericardial vacuity, usually as a result of an inflammatory or infectious process. A sudden accumulation of even 200ml of fluid may raise intracardiac pressure to levels that will cause symptoms similar to right-sided heart failure. Pericarditis is inflammation of the pericardium while COPD is a respiratory disease.
A client who is experiencing angina at rest that has been increasing in intensity should be instructed to do which of the following?
See the doctor for evaluation immediately. Explanation: Angina that occurs at rest, is of new onset, or is increasing in intensity or duration denotes an increased risk for myocardial infarction and should be seen immediately using the criteria for acute coronary syndrome (ACS).
The diagnosis of chronic stable angina is based on a detailed pain history, the presence of risk factors, invasive and noninvasive studies, and laboratory studies. What test is not used in the diagnosis of angina?
Serum biochemical markers Explanation: Serum biochemical markers for MI are normal in clients with chronic stable angina. All other answers are tests used in the diagnosis of angina.
A client was in car accident client while not wearing a seatbelt and has sustained multiple rib fractures. During assessment, the nurse is having a hard time hearing heart sounds, and the client reports chest pain/pressure repeatedly. This client may be experiencing:
Pericardial effusion. It is the accumulation of fluid in the pericardial cavity, usually as a result of an inflammatory reaction. It may develop with neoplasms, cardiac surgery, or trauma. Pericardial effusion exerts its effects through compression of the heart chambers. The normal pericardial space contains about 15 to 50 mL of fluid. Increases in the volume of this fluid, the rapidity with which it accumulates, and the elasticity of the pericardium determine the effect that the effusion has on cardiac function. This leads to cardiac standstill or failure. Pericardial sac thickening due to inflammation can restrict the heart, rather than to allow stretching. Rupture of the sac is pathologic, resulting in heart expansion. A friction rub sound (rubbing between the inflamed pericardial surfaces) is characteristic of acute pericarditis. Acquired cardiomyopathies include those that have their origin in the inflammatory process (e.g., myocarditis), pregnancy (peripartum cardiomyopathy), and stress (takotsubo cardiomyopathy). In congenital heart defects, in most cases, pulmonary vascular resistance is only slightly elevated during early infancy, and the major contribution to pulmonary hypertension is the increased blood flow.
A client is seen in the emergency room with complaints of sharp chest pain that started abruptly. He says it has radiated to his neck and abdomen. He also states that it is worse when he takes a deep breath or swallows. He tells the nurse that when he sits up and leans forward the pain is better. Upon examination the nurse notes a pericardial friction rub and some EKG changes. Which disease should the nurse suspect this client to have?
Pericarditis Explanation: This patient is demonstrating signs and symptoms of pericarditis, which includes a triad of chest pain, pericardial friction rub, and EKG changes. Other signs are that the pain is usually abrupt in onset, occurs in the pericardial area, and may radiate to the neck, back, abdomen or side. It is usually worse with deep breathing and swallowing, and the person often finds relief when sitting up and leaning forward.
The nurse caring for a patient 12 hours post coronary bypass graft notes a sudden decrease in the amount of chest tube drainage, a rapidly narrowing pulse pressure, paradoxical pulse, and shortened amplitude of the QRS complex on the electrocardiogram monitor. Which of the following should the nurse do next?
Prepare for pericardiocentesis Explanation: Cardiac tamponade develops when cardiac filling is reduced by the accumulation of fluid in the pericardial sac. This may occur after cardiac surgery or as a result of trauma or infection. The volume and speed of fluid accumulating in the pericardial sac determines how critical the situation is. A large or rapidly developing effusion often requires pericardiocentesis to remove it. Small effusions may be treated with nonsteroidal anti-inflammatory drugs and corticosteroids.
A client is at high risk for the development of rheumatic heart disease. The most important information for the nurse to provide would be:
Prompt diagnosis and treatment of streptococcal infections Explanation: Rheumatic heart disease is normally caused by streptococcal infections; therefore, early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a client has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and the client should have regular dental examinations.
A preventative measure to decrease the risk of developing rheumatic heart disease includes which of the following?
Prompt diagnosis of streptococcal infections with a throat culture Explanation: Rheumatic heart disease is normally caused by streptococcal infections; therefore early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a patient has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the patient may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.
The initial medical management for a symptomatic patient with obstructive hypertrophic cardiomyopathy (HCM) would be administering a medication to block the effects of catecholamines. The nurse will anticipate administering which of the following medications?
Propranolol, a β-Adrenergic blocker. Explanation: β-adrenergic blockers are generally the initial choice for persons with symptomatic HCM. Calcium channel blockers can also be used. ACE-inhibitors, diuretics, or positive inotropics are not the initial first-line medications.
The initial medical management for a symptomatic patient with obstructive hypertrophic cardiomyopathy (HCM) would be administering a medication to block the effects of catecholamines. The nurse will anticipate administering which of the following medications?
Propranolol, a β-Adrenergic blocker. Explanation: β-adrenergic blockers are generally the initial choice for persons with symptomatic HCM. Calcium channel blockers can also be used. ACE-inhibitors, diuretics, or positive inotropics are not the initial first-line medications.
A teenager is seen in the emergency room with complaints of a sore throat, headache, fever, abdominal pain, and swollen glands. His mother tells the nurse that he was seen three weeks before in the clinic and treated with antibiotics for a strep throat. He was better for a few days but now he seems to have gotten worse in the last two days. What should the nurse suspect is wrong with this client?
Rheumatic fever Explanation: Rheumatic fever is an immune-mediated inflammatory disease that occurs a few weeks after a group A strep (sore throat). It can manifest as an acute, recurrent or chronic disorder.
An IV drug abuser walks into the ED telling the nurse that, "they are sick." They look feverish with flushed, moist skin; dehydrated with dry lips/mucous membranes; and, fatigued. The assessment reveals a loud murmur. An echocardiogram was order that shows a large vegetation growing on their mitral valve. The patient is admitted to ICU. The nurse will be assessing this patient for which possible life-threatening complication?
Systemic emboli, especially to brain. Explanation: Systemic emboli and develop and break off the mitral valve and travel into the vascular system. There is a high probability that the emboli could lodge in the brain, kidneys, lower extremities, etc. B—petechial hemorrhages are s/s of IE. GI upset is common following antibiotic therapy but is not usually life-threatening. Stress can increase insulin needs but not associated with pancreas enlargement.
Which of the following patients is at the greatest risk of developing rheumatic heart disease?
Teenager with untreated strep throat Explanation: Rheumatic fever is caused by group A (beta-hemolytic) streptococcal throat infection. Although the same bacteria cause the skin infection called impetigo, it is not known to cause rheumatic heart disease. Viral infections such as meningitis and shingles (herpes zoster) do not cause rheumatic heart disease.
The nursing instructor is teaching the students about rheumatic fever. She tells the students that it is an important cause of heart disease and is very serious mainly for which reason?
The disabling effects that result from involvement of heart valves Explanation: Rheumatic fever is a very important cause of heart disease and its most serious and disabling effects result from involvement of the heart valves.
A client has just been admitted to the cardiac intensive care unit with a diagnosis of infective endocarditis. His wife appears distraught and asks the nurse what caused this to happen to her husband. What would be the nurse's best response?
The most common cause is a staph infection. Explanation: Staphylococcal infections have now emerged as the leading cause of infective endocarditis, with streptococci and enterococci as the other two most common causes. Informing the client's wife about the drug abuse connection infers that you think he is a drug addict and is not therapeutic. Parasites are never the cause and telling the patient to focus on her husband also is not appropriate as this is a genuine concern for her.
A client has been diagnosed with aortic stenosis and asks the nurse what this means. The most appropriate response would be:
The valve opening is narrowed and produces increased resistance to blood flow out of the left ventricle and into the aorta. Explanation: Stenosis refers to a narrowing of the valve orifice and failure of the valve leaflets to open normally. This increases the work and volume of the chamber emptying through the narrowed valve—the left atrium in the case of mitral stenosis and the left ventricle in aortic stenosis. An incompetent or regurgitant valve permits backward flow to occur when the valve should be closed—flowing back into the left ventricle during diastole when the aortic valve is affected and back into the left atrium during systole when the mitral valve is diseased.
In infective endocarditis, vegetative lesions grow on the valves of the heart. These vegetative lesions consist of a collection of infectious organisms and cellular debris enmeshed in the fibrin strands of clotted blood. What are the possible systemic effects of these vegetative lesions?
They can fragment and cause cerebral emboli. Explanation: The intracardiac vegetative lesions also have local and distant systemic effects. The loose organization of these lesions permits the organisms and fragments of the lesions to form emboli and travel in the bloodstream, causing cerebral, systemic, or pulmonary emboli. Preventing the valves of the heart from either opening or closing completely is not a systemic effect of the lesions. Fragmentation of the lesions does not make them larger.
Which serum biomarker is highly specific for myocardial tissue?
Troponin Explanation: The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.
A client comes to the emergency room with all the symptoms of a myodardial infarction. Which lab value does the nurse suspect the physician will order which is known to have a high specificity for myocardial tissue and has become the primary biomarker test for diagnosing an MI?
Troponin assays Explanation: The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction. Creatine kinase is an intracellular enzyme found in muscle cells. The troponin level identifies necrosis in cardiac muscles earlier than creatine kinase. The others are not necessarily used when suspecting a myocardial infarction.
A client with a suspected MI is brought to the emergency department by ambulance. The nurse caring for this client would expect to receive an order for which laboratory test to confirm a diagnosis of MI?
Troponin level Explanation: The troponin assays have high specificity for myocardial tissue and have become the primary biomarker for the diagnosis of myocardial infarction (MI). The troponin complex, which is part of the actin filament, consists of three subunits (i.e., TnC, TnT, and TnI) that regulate calcium-mediated actin-myosin contractile process in striated muscle (see Chapter 1, Fig. 1-19). TnI and TnT, which are present in cardiac muscle, begin to rise within 3 hours after the onset of MI and may remain elevated for 7 to 10 days after the event. This is especially adventitious in the late diagnosis of MI. The other blood work may be ordered, but not to confirm the diagnosis of MI.
Following cardiac surgery, the nurse suspects the patient may be developing a cardiac tamponade. Which of the following clinical manifestations would support this diagnosis? Select all that apply.
• Low BP—84/60. • Narrowed pulse pressure. • Muffled heart tones. Explanation: Cardiac tamponade results in increased intracardiac pressure, progressive limitation of ventricular diastolic filling, and decreased stroke volume and cardiac output. This accumulation of fluid results in tachycardia, elevated CVP, jugular vein distention, fall in systolic BP, narrowed pulse pressure and signs of shock. Heart sounds may be muffled. A pulse rate of 78 is normal (not tachycardic). With pulsus paradoxus, the arterial pulse as palpated at the carotid or femoral artery becomes weakened (not bulging) or absent with inspiration.
A client is brought to the emergency department presenting with symptoms of ACS (acute coronary syndrome). Select the most important interventions that should be implemented. Select all that apply.
• Oxygen • Morphine • Nitrates • ECG monitoring • β-adrenergic blocking agents Explanation: For any person presenting with symptoms of ACS, providers should perform a 12-lead ECG and continuous ECG monitoring. Treatment regimens also include administration of oxygen, aspirin, nitrates, morphine, antiplatelet and anticoagulant therapy, β-adrenergic blocking agents (beta-blockers), and an angiotensin-converting enzyme (ACE) inhibitor. Acetaminophen is not a treatment of choice.
A client who has been admitted to the emergency room with symptoms of a STEMI is given nitroglycerine. The nurse explains to the client's wife that this medication is given for which of the following reasons? Select all that apply.
• To relieve coronary pain • For its vasodilatation effect Explanation: Nitroglycerine is given in the treatment of STEMI because of its vasodilating effect and its ability to relieve coronary pain.
